* If sumatriptan is not effective, it is worthwhile to use another triptan. Because triptans are far superior to our other choices, it is worthwhile to try at least 3 before giving up on the class.
* NSAIDS (she is on naproxen); NSAIDS are not addicting and do not cause fatigue. Cambia is a powdered form of diclofenac potassium and is FDA-approved for acute migraine; NSAIDS may be combined with triptans.
* Prodrin This is a good combination of isometheptene (a mild vasoconstrictor), 20 mg caffeine, and acetaminophen. Prodrin fits the bill as a nonaddicting or sedating, milder medicine and is useful for moderate headaches. We need to be careful with the amount of caffeine, however.
* Dihydroergotamine (DHE) is primarily a venoconstrictor, not arterial, rendering it safer than other ergots.
* We would also consider other antiemetic medications, such as prochlorperazine. We did not prescribe ondansetron, one of the antiemetics that do not cause sedation.
Six weeks later, Heather reports that the topiramate has lessened the frequency of the migraines, and the daily headaches are not quite as severe. However, she is having a difficult time with her memory, and does not feel that she can increase the dose past 50 mg. The depression is possibly worse on the topiramate, but she wishes to continue with it, as it “is the first drug that has decreased the severity of my headaches.”
Over the counter (OTC) naproxen helps her to some degree, and she is limiting her caffeine to 150 mg daily. For the migraines, the sumatriptan helps only 25%, but the ondansetron is effective for her nausea.
Heather has begun to see a psychotherapist, who is teaching her to do biofeedback. She feels that this is helpful. She is exercising 20 minutes daily, on average.
We choose to continue with the topiramate, as it has helped. We cannot increase the dose due to the cognitive side effects of the medication. Because of the depression, which is probably bipolar, we add quetiapine. It is important to with low doses of quetiapine, as many patients will quit the drug due to sedation. We start with 25 mg at night, and increase to 50 mg after 1 week. The atypicals carry the warning of an increased risk for developing diabetes and, of course, this must be communicated through informed consent. For most patients, I try to use as low a dose as is effective. Naturally, we warn Heather about possible sedation and weight gain. Some bipolar patients will have a paradoxical reaction to certain atypicals and actually experience hypomania, usually mild. For the patient with bipolar disease, lithium carbonate is a strong consideration.
Next up, the conclusion to Heather’s case study.